Healthcare Provider Details

I. General information

NPI: 1194857292
Provider Name (Legal Business Name): ODD FELLOW AND REBEKAH REHABILITATION AND HEALTH CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 OLD NIAGARA RD
LOCKPORT NY
14094-1500
US

IV. Provider business mailing address

104 OLD NIAGARA RD
LOCKPORT NY
14094-1500
US

V. Phone/Fax

Practice location:
  • Phone: 716-434-6324
  • Fax: 716-434-4020
Mailing address:
  • Phone: 716-434-6324
  • Fax: 716-434-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3101305N
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number3101305N
License Number StateNY

VIII. Authorized Official

Name: MRS. DARLENE SUE DICARLO
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 716-434-6324